Field Ambassador Manager - Generation 5

• Ambassador name

• Tech number

• Conducted on

  Date

• Prepared by

Ambassador Manager Risk Assessment

• Are there any hazards?

  Yes

  No

• Hazard Type

  Select Traffic Ground Third Party Weather Pets

  • Traffic
  • Ground
  • Third Party
  • Weather
  • Pets

• Are the hazards controllable?

  Yes

  No

• Details

• Visit Type

  Select Field Visit Meeting Feedback 121 IDD RTW

  • Field Visit
  • Meeting Feedback
  • 121
  • IDD
  • RTW

• Appearance (personal, PPE, uniform etc)

• Equipment

• Van

• Communication

• Meeting Type

  Select Engineer Team Meeting Time to Learn Team Time Ambassador Team Meeting Regional Meeting Other

  • Engineer Team Meeting
  • Time to Learn
  • Team Time
  • Ambassador Team Meeting
  • Regional Meeting
  • Other

• Date and time of the meeting

  Date

• Details of the meeting (Organiser, location etc)

• What did the Ambassador deliver in the meeting?

• Reason for 121

  Select Praise/Reward Governance Safety DriveSafe Personal Matter Other

  • Praise/Reward
  • Governance
  • Safety
  • DriveSafe
  • Personal Matter
  • Other

• Details

• Reason for IDD

• Time and date of incident

  Date

• FAM

• Ambassador

• FAM

• Ambassador

• FAM

• Ambassador

• FAM

• Ambassador

• Media to support IDD

  Media

• Type of absence

  Select Short Term Sickness Long Term Sickness Paid/Authorised Absence Unpaid/Unauthorised Absence

  • Short Term Sickness
  • Long Term Sickness
  • Paid/Authorised Absence
  • Unpaid/Unauthorised Absence

• First date of absence

  Date

• Last date of absence

  Date

• Absence reason

  Select Alcohol/Drug Addiction Allergy Asthma (excl work related) Blood disorder Breast problems Cancer/tumors Chest/respiratory problems Cold/cough/flu Dental Diabetes/Thyroid/Endocrine Disease of nervous system Ear/nose/throat condition Epilepsy/neurological Eye problem Gastrointestinal problems Gynae including period pains Headache/migraine Heart/BP/Cirulatory Infectious disease Kidney/bladder problems Non work injury/burn/fracture/RTA Non work musculoskeletal problem Occupational asthma Occupational dermatitis Pregnancy related Stress/anxiety/depression (non work) Stress/anxiety/depression (work related) Swine flu Unknown cause Vertigo/dizziness/insomnia Virus Work injury/burn/fracture/RTA Work related musculoskeletal problem Work related back/disc problem Other

  • Alcohol/Drug Addiction
  • Allergy
  • Asthma (excl work related)
  • Blood disorder
  • Breast problems
  • Cancer/tumors
  • Chest/respiratory problems
  • Cold/cough/flu
  • Dental
  • Diabetes/Thyroid/Endocrine
  • Disease of nervous system
  • Ear/nose/throat condition
  • Epilepsy/neurological
  • Eye problem
  • Gastrointestinal problems
  • Gynae including period pains
  • Headache/migraine
  • Heart/BP/Cirulatory
  • Infectious disease
  • Kidney/bladder problems
  • Non work injury/burn/fracture/RTA
  • Non work musculoskeletal problem
  • Occupational asthma
  • Occupational dermatitis
  • Pregnancy related
  • Stress/anxiety/depression (non work)
  • Stress/anxiety/depression (work related)
  • Swine flu
  • Unknown cause
  • Vertigo/dizziness/insomnia
  • Virus
  • Work injury/burn/fracture/RTA
  • Work related musculoskeletal problem
  • Work related back/disc problem
  • Other

• Is the absence work related

  Select Yes No

  • Yes
  • No

• Details

• Is it a linked absence?

  Yes

  No

• Details

• Did the Ambassador visit their GP during their absence?

  Yes

  No

• Is the Ambassador currently on an medication?

  Yes

  No

• Number of absences in rolling 12 months

  Select 1 2 3 4 5 6 7 8 9 10+ First absence

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10+
  • First absence

• Percentage absence in rolling 12 months

  Select 0 - 1.59% 1.6 - 3.59% 3.6 - 5.59% 5.6 - 8.49% 8.5% +

  • 0 - 1.59%
  • 1.6 - 3.59%
  • 3.6 - 5.59%
  • 5.6 - 8.49%
  • 8.5% +

• Occupational Health referral required?

  Yes

  No

• Details

• Reason for absence

• Any follow up considerations

• Media to support

  Media

• Ambassador

  Sign

• Field Ambassador Manager

  Sign